The answer to the question of which is the best test lies in the timing of the particular examination relative to the course of the disease. For the initial diagnosis and institution of therapy, the flexible sigmoidoscopic examination, which visualizes the mucosa in the distal colon, coupled with a barium enema to evaluate the entire large bowel is a timetested and well-defined method for making the diagnosis of inflammatory bowel disease (1-3). The vast majority of patients with inflammatory bowel disease do not require colonoscopy for either the initial diagnosis or for interim decisions that must be made during the illness (4).
The colonoscopic view of mucosal involvement is about twice as accurate as the barium enema estimate of extent of disease, and the biopsy determination of inflammatory activity is about three times more informative than the x-ray examination (5). However, this information is rarely of importance in the institution of or choice of therapy, which is based on the clinical evaluation of the patient.
Most decisions in the course of inflammatory bowel disease, whether it be treatment of toxic megacolon, the need for surgery in an acutely ill and debilitated patient with fulminating colitis, or the advice to a patient with short stature syndrome, are not usually predicated on the outcomes of a colonoscopic evaluation. The decisions are based on the overall evaluation, taking into account the laboratory parameters and the clinical status of the patient as determined by observation, history, and physical examination (6,7). There have been two recent articles in the literature (8,9) stating that patients with fulminating colitis in which surgery is imminent